Physiotherapy with 9 of 18 basic strengthening exercise for correct lumbar hyper - lordosis induce low back pain (ep.1)

 

McGill curl up exercise
(Ref: https://www.pinterest.com/)

The lumbosacral region is the most important region in the vertebral column in terms of mobility and weight bearing. Mechanical disorders of this region cause LBP. One of the most common causes of LBP is lumbar spinal curve change. Spinal curvature in the lateral view is necessary for effective weight bearing, increasing efficiency of paraspinal muscles, and maintaining erect posture. 

Normal lumbar lordosis angle ranges from 30º to 45º. An abnormal curve of the spine can increase stress on the body which can lead to muscle imbalance. One of the most important postural deformities of the spinal column is lumbar hyper-lordosis which means exaggerated curve of lumbar spine. 

Normal lumbar lordosis angle
(Ref: https://www.jssm.org/volume10/iss2/cap/jssm-10-355.pdf)

Some studies have shown that muscles can provide segmental stabilization by controlling motion in the neutral zone. Weakness in any of the muscles of the lumbar-pelvic belt can cause diversions of back arch by impairing muscular balance in this area. The balance of the muscles around the pelvis is an important factor in maintaining lumbar lordosis. Because  of the relationship between the sacrum and the pelvis through the spine, any change in the biomechanics of the sacro-pelvic region leads to changes in spinal curvatures, especially lumbar lordosis.

Following are some causes for hyper-lordosis i.e. bad posture, obesity, Lack of exercises, sedentary lifestyle, shifting of line of gravity during pregnancy, use of footwear with high heels. Bad posture causes hyper-lordosis can be corrected with exercises that should focus stretching on hip flexors and back extensors and abdominal muscles and hip extensors will be strengthened.

Muscle imbalance in lumbar hyper-lordosis and anterior pelvic tilt
(Ref: https://www.semanticscholar.org/paper/Effects-of-a-massage-therapy-program-on-functional-Wong/59d1cdb704700562cd73e420cfb73ead2eda8e67)

Therapeutic exercise to posterior pelvic tilt, the lower abdomen is pulled up and in, and the pelvis is tilted posteriorly to flatten the low back on the table by action of the external oblique, especially the posterior lateral fibers. Patients should avoid using the gluteus maximus to tilt the pelvis when doing this exercise. Pelvic tilt may be done with the rectus abdominis, but should not be done in this manner when emphasis is on strengthening the external oblique.

To correct anterior pelvic tilt, posterior pelvic tilt exercises are indicated. The movement should be done by the external obliques, not by rectus nor by hip extensors. The effort must be made to pull upward and inward with the abdominal muscles, making them very firm, particularly in the area of the lateral external oblique fibers.

Basic 9 of 18 therapeutic strengthening exercise to posterior tilt (Remark: If there is tightness of the back extensors or hip flexors, it is necessary to treat these muscles to restore normal length before the abdominals can be expected to function optimally that can learn more on https://yimphysionearme.blogspot.com/2022/09/physiotherapy-with-6-stretching.html )

Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week.

Exercise #1: Basic supine posterior pelvic tilt: Supine with both knees bending, then

squeeze belly for flatten lumbar spine with floor. Do not roll pelvic backward by feet

pushing or glut contraction.

Exercise #2: Supine posterior pelvic tilt with raise arms to ears: Supine with both knees

bending, then squeeze belly for flatten lumbar spine with floor. Hold this pelvic position, and

raise both arms to ears. Do not roll pelvic backward by feet pushing or glut contraction.

Exercise #3: Supine heel slide: Supine with squeeze belly for flatten lumbar spine on the

floor. And hold this pelvis position all the time when bend knee by drag heel on - off buttock.

Exercise #4: McGill curl up: Supine with squeeze belly for flatten lumbar spine on the floor.

And hold this pelvis position all the time when lift up and down head and upper rib from the

floor.

Exercise #5: Single knee to chest: Squeeze belly and hold the muscle all the time when lift

the knee up and down. During lifting knee to chest, need elevate distal hip in the same

time.

Exercise #6: Double knees to chest: Squeeze belly and hold the muscle all the time when

lift the knee up and down. During lifting knee to chest, need elevate distal hip in the same

time.

Exercise #7: Single bridging

Exercise #8: Squat: Stand with both feet parallel, about shoulder’s width apart. Attempting

to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet

flat on the floor, the subject slowly lowers his body by flexing his knees.

Exercise #9: Cable trunk rotation: rotate rib level - do not include pelvic. You can apply this exercise

with weight cable machine or elastic band.

Muscle weakness of pelvic anterior tilt or hyper - lordotic lumbar spine

(1) Anterior abdominal muscles

Weakness of anterior abdominal muscles allows the pelvis to tilt forward while the low

back is drawn into a position of lordosis. The muscles are incapable of exerting the upward

pull on the pelvis that is needed to help maintain a good alignment. 

Abdominal wall muscle contraction induce pelvic posterior tilt & flatten back
(Ref: https://knotry.com/)

The patients with lumbar lordosis who have abdominal muscle weakness is the main

problem and usually complains of pain across the low back. It is described as fatigue in the

early phase, and later as an ache which may or may not progress to being acutely painful. 

Pain always gets worse at the end of day and is relieved by recumbency to such an

extent that after a night’s rest the individual may be free of symptoms. Sleeping on a firm

mattress allows the back to flatten and this change from the lordotic position gives relief and

comfort to the patient.

Prolonged abdominal muscle lengthening can develop muscle weakness that is

present during pregnancy and obesity. Physiotherapists often give patients a list of

exercises intended to strengthen these muscles. Unfortunately, these lists have included

sit - ups and double - leg - raising exercises that should not be given when abdominal

muscles are very weak.

double - leg - raising exercises with back arch indicated weakness of abdominal muscle (Ref: http://www.smscs.dreamhosters.com/wp-content/uploads/201601/ablegloweringtest.pdf)

(2) Hip extensor muscles

Hip extensors consist of the one - joint gluteus maximus and the two - joint hamstring

muscles. Weakness of these muscles is seldom found as the primary factor in anterior

pelvic tilt, but when found in conjunction with hip flexor shortness or abdominal muscle

weakness, the pelvic tilt and lordosis tend to be more exaggerated than if the hip extensor

weakness were not present.

Slight to moderate weakness if the gluteus maximus and hamstring muscles will allow

the pelvis to tilt forward in the standing position. Weakness of the hamstrings alone would

not affect the pelvic position to the same extent. 

Sway - back posture
(Ref: https://pamofit.wordpress.com/2014/09/08/case-study-cystic-fibrosis-the-impact-on-posture/)

In extreme weakness, the only stable position of the hip is obtained by the sway - back

posture that displaces the pelvic forward and the upper trunk backward for distributing the

body weight over the center of gravity with the hip joint locked in extension and the pelvis in

posterior tilt. 

Exercise to strengthen hamstrings can then be added in the form of resisted knee

flexion with the hip flexed, or prone knee flexion with the hip extended. In a prone position

the knee should not be flexed to the extent that this two - joint muscle is at an angle of

approximately 50 deg to 70 deg of knee flexion in the prone position.

Hamstring and low back stretching
(Ref: https://www.verywellfit.com/)

In the standing position, hamstring muscles may feel taut whether they are stretched

or short. Faulty postural alignment is indicative of hamstring length consisting of a

lordosis of stretched hamstrings; inflat - back and sway - back postures, hamstrings

tend to be short.

Reference:

https://mjcu.journals.ekb.eg/article_125150_c1c109ac4d5ee217000db816f2bfa8f1.pdf 

http://cdeporte.rediris.es/revista/inpress/artprevencion1278e.pdf

https://medicopublication.com/index.php/ijpot/article/view/14504

https://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.684.8367&rep=rep1&type=pdf

Kendall FP., et al. Muscles testing and function. Fourth edition. Williams & Wiikins. USA.

1993.